AG: So the vendors really have little incentive to standardize, because true interoperability would mean they never have a captive client?
LF: Exactly. That is exactly right, so it is not going to happen but it is a nice dream. But I am going to be interested, as I go into my golden years and start to become a consumer of healthcare, I’m going to be interested to see how it continues to evolve. It certainly has evolved. I mean having been involved in this from a technology standpoint for the last 27 years, I have just seen huge changes, but at the time they were happening they didn’t feel so huge. Looking back in retrospect, they really are: the ability to use physician support systems, to track core measures, to make sure that patient safety initiatives have been implemented, and that the standards have embraced most of them. The ability to say, ‘I have got a patient in the emergency room that is short of breath and coughing,’ and have the system come back and say, ‘Did you think about giving them an antibiotic for pneumonia,’ since the national safety goals are that you get an antibiotic within an hour of presenting in an emergency department with symptoms of pneumonia. Well now you don’t have to depend on the person to remember to do that. The system tweaks them. It doesn’t make them give it, but it tweaks them. That is a big deal.
I just see examples of it over and over again and that part I find exciting. I really get excited about that stuff, because the Institute of Medicine came out with their study on errors in hospitals, and we actually did a flowchart of what happens to a pharmacy order from the time the physician orders it until it is given to the patient. It was phenomenal, and we did this 10 years ago, but there were about 50 distinct steps in that process, and 20-some places where an error could be made from the doctor writing it, to the clerk translating the doctor’s handwriting, to the nurse looking at it and sending an order to the pharmacy. It just went on and on and on, right up to the point of picking the medicine out of the drawer and giving it to the patient at any one of those places. It actually is amazing that anybody ever gets a drug administered correctly, and yet technology has proven over and over again that it can help with that process. It can make sure that you get the right drug to the right patient at the right time.
And so that part of it is exciting, going from basically admitting billing systems, which are pretty boring, to getting into the patient care arena, and seeing all the things that can be done. That has been exciting.
AG: Patient safety initiatives depend on data flow and integration, so how do you handle that? Do you have an interface engine?
LF: We do. Yes, it is Quovadx.
AG: Does having an interface engine solve your cross-vendor integration problems?
LF: It doesn’t solve it. It allows us, to some extent, to solve them ourselves, but it is cumbersome, and it’s a big job. But that’s how we do it. We basically bring something into the interface engine, and if it needs to be tweaked, I have got two people that know how to program that, so that it can be changed to what the other system is expecting. But you have to build the translation tables. Translation tables can be a huge job, especially when you’ve got hundreds of orders and thousands of drugs, and I don’t know how many allergies there are in the world, but it seems like there are a lot. It’s growing every day.
Yes, an interface engine is key. I don’t think you could run an efficient best-of-breed structure without an interface engine. Frankly, not even a best of suite, because you are always going to have some standalone systems.
In our environment, my best example of that is we have a separate vendor for our OB/GYN for labor and delivery for their documentation, but it started as a software that ran off of the fetal monitors. My standard HIS vendor doesn’t have anything that directly integrates to the fetal monitor so that I can chart right on the monitor script what is going on, and that is what they need to be able to do. So that is such a specialized need that a big HIS vendor is never going to have that. It’s always going to be a little standalone vendor.
AG: Unless they snatch up the vendor.
LF: Unless they snatch up the vendor, but even if they do that, it is still going to be a standalone product sitting with their suite of applications.
AG: They are not going to integrate it on their end?
LF: It won’t be fully integrated. They never are. They are interfaced.
AG: What is the difference between interfaced and integrated?
LF: Interfaced means I have system A, I have system B, and I have something in between, either point to point with cable or an interface engine that brings the data out of one and puts it into the other. Integrated says I have a single database, it’s all stored in that one database and all of my modules within my system access that database.
AG: So a lot of times, if they snatch up a vendor, they may present it as an integrated system, but it is really just interfaced?
LF: That is exactly right. Let’s say I’ve got a hospital information system but I’m missing a pharmacy system, so I have got to buy a pharmacy system. That pharmacy system is still going to look to its own database to get the patient’s name and it is not going to look to the big hospital information system database. That is the difference. It will send it over and it will be transparent to the users, but it is not transparent to IT, especially when something goes wrong with that interface.
AG: So is that something that you put in the RFP? It sounds like you have to be very specific with what you’re asking to get the true picture.
LF: Yes, and it’s also one of our technology reference questions: how are the files stored? Describe for us your database structures. Describe for us where your patient information is stored. If they start describing four or five or six different databases, I know I’m dealing with a vendor that has got a bunch of interface products.
AG: Is this the biggest challenge of the job? I was speaking to a CIO who said her biggest challenge is attracting and retaining talent in the IT shop. What do you think is the main challenge you face in your position?
LF: That is an interesting question, because I have two or three and I’m not sure what the main one would be. Retaining good people hasn’t been a problem. I have got incredible retention on this staff. I think my average length of stay, with my 28 people, is right around 12 years. So that is not an issue for me, and most of the new people are in new positions, newly defined, newly described positions.
I’ve got two issues. One is getting administration and the board to buy into the purchase of technology. Technology is expensive and they have hard time with it. They really do, and it is not just the technology. It’s the fact that, ‘You mean to tell me I’m going to go out and spend $500,000 on this system, and then I’m going to pay another $70,000/year to maintain it.’ That maintenance just kills them. As far as they are concerned, they are re-buying it every five years, and they are. But every five years, the product has probably been changed quite a bit. We could get into a whole philosophical conversation of whether it’s worth it or not, but that’s what it is. It is what it is. The technology is expensive and getting buy-in from the C-suite executives who are not technically oriented is a challenge. We do it all the time, but it is a challenge.
Getting participation and buy in from our physicians is also a challenge. We are a community hospital. These are physicians who are based in their own offices and they have privileges at our hospital, but they don’t work for us. They also have privileges at Georgetown and GW and Suburban, so if I make them mad, they're going down the road. So that is a challenge: getting them what they need, making it cost effective, communicating with them, and getting them buying into that whole philosophy I have of getting user buy in. I can get that pretty easily with hospital staff, because it simply becomes part of their jobs. But when it is the physician staff, it’s a little bit more difficult because they're not getting paid for the time that they spend on committee meetings and things like that, or evaluating systems with me, or giving me their feedback on whether they think this functionality will meet their needs. It is a constant struggle to maintain some continuity with physicians and get their participation, because they are in business. Time is money to them too.
I would say those are probably my two biggest challenges right now, and then the integration of data is. For me, building the electronic health record is huge because everybody has a stake in that. The physicians have a stake in that. The IT department has a stake in that. Every user department has a stake in that. That would be another one on my list. I have a quiet a few challenges.
AG: How much money do you have to get all of that done? Can you tell me your IT annual budget?
LF: My operating budget is about $2.4 million.
AG: Since 1973, you have been in this business, giving you a perspective that many CIOs do not have. What would your advice be to your junior peers?
LF: Well, first of all, it is so important today that they have a clear understanding of their organization’s overall goals and objectives. If they're not getting that information, they need to get out and get it. They need to talk to people. They’ve got to communicate, and I think IT people are notoriously bad at doing that. I would say communicating with your peers, and with department heads, and having that constant dialog is incredibly important.
Then, from my perspective, it is hiring good staff and trusting them to make the decisions. I can’t say enough about the people that work for me in terms of they know what is expected of them and they do it. They know when to come and get help. I don’t have a bunch of people whining at me. I have people that come in and say, ‘I have got a problem. This is what I think the solution is. What do you think?’ That’s worth its weight in gold. So my advice would be to surround yourself with good people, to the extent that you can. If you do that, the rest of it all falls into place.
I think if I had to credit one thing on my success, one reason for my success over the years, it would have to be communication. I’m a good communicator, and I encourage that in everybody I work with. We might not always like what the other one has to say, but you have to be willing to listen to it. Everybody has a point of view.